4-hour Blocks Research Articles

PROGNOSTIC PERFORMANCE OF SERIAL DETERMINATION OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SHOCK CLASSIFICATION IN ADULTS WITH CRITICAL ILLNESS.

Purpose: The aim of the study is to evaluate whether serial assessment of shock severity can improve prognostication in intensive care unit (ICU) patients. Materials and Methods: This is a retrospective cohort of 21,461 ICU patient admissions from 2014 to 2018. We assigned the Society for Cardiovascular Angiography and Interventions (SCAI) Shock Stage in each 4-h block during the first 24 h of ICU admission; shock was defined as SCAI Shock stage C, D, or E. In-hospital mortality was evaluated using logistic regression. Results: The admission SCAI Shock stages were as follows: A, 39.0%; B, 27.0%; C, 28.9%; D, 2.6%; and E, 2.5%. The SCAI Shock stage subsequently increased in 30.6%, and late-onset shock developed in 30.4%. In-hospital mortality was higher in patients who had shock on admission (11.9%) or late-onset shock (7.3%) versus no shock (4.3%). Persistence of shock predicted higher mortality (adjusted OR = 1.09; 95% CI = 1.06-1.13, for each ICU block with shock). The mean SCAI Shock stage had higher discrimination for in-hospital mortality than the admission or maximum SCAI Shock stage. Dynamic modeling of the SCAI Shock classification improved discrimination for in-hospital mortality (C-statistic = 0.64-0.71). Conclusions: Serial application of the SCAI Shock classification provides improved mortality risk stratification compared with a single assessment on admission, facilitating dynamic prognostication.

Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients.

One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.

Abstract 13964: Dynamic Assessment of Shock Severity in Cardiac Intensive Care Unit Patients

Introduction: A single assessment of the SCAI shock classification robustly predicts mortality, and a repeat assessment may improve prognostication. Hypothesis: We hypothesized that frequent serial assignment of the SCAI shock stage could further improve risk stratification. Methods: Unique AHA Level 1 cardiac intensive care unit (CICU) admissions at a single center from 2015 to 2018 were reviewed retrospectively. Time-stamped electronic health record data were used to assign the SCAI shock stage in each 4-hour block during the first 24 hours of CICU admission. Shock was defined as SCAI shock stage C, D, or E. In-hospital mortality was evaluated using logistic regression. Results: Among 2,918 CICU patients, 1,537 (52.7%) met criteria for shock during &gt;=1 block and 266 (9.1%) died in hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; E, 3.3%. Patients with worsening SCAI shock stage after admission (first 4 hours) were at higher risk of mortality ( Figure A ), as were patients who met SCAI criteria for shock (particularly those with shock on admission, Figure B ). The pattern was consistent in patients with acute coronary syndromes, heart failure, or cardiac arrest (who had very high mortality). Each higher admission (aOR 1.36, 95% CI 1.18-1.56, AUC 0.70), maximum (aOR 1.59, 95% CI 1.37-1.85, AUC 0.73) and 24 hour mean (aOR 2.42, 95% CI 1.99-2.95, AUC 0.78) SCAI shock stage were incrementally associated with increasing in-hospital mortality. Discrimination was highest for the mean SCAI shock stage (p &lt;0.05). Each additional 4 hour block meeting SCAI criteria for shock was associated with higher mortality (aOR 1.15, 95% CI 1.07-1.24). Conclusions: Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients. Cumulative time in shock was a strong mortality risk indicator, highlighting the area under the curve of shock severity as an important determinant of outcomes.

Physical activity is a potential measure of physical resilience in older adults receiving hemodialysis.

Physical resilience, or the ability to recover after a physical stressor, declines with aging. Efforts to preserve physical resilience in the older dialysis population are critically needed; however, validated, patient-centered measures that are sensitive to change are also needed. Our objective was to assess accelerometer-derived step count variability, or a measure of intra-individual variation in physical activity, as a potential measure of physical resilience among older adults receiving hemodialysis. Community-dwelling ambulatory older adults receiving in-center hemodialysis were prospectively enrolled. Participants wore wrist accelerometers during daytime hours on both dialysis and non-dialysis days up to 14 days, and the feasibility of accelerometer use was assessed from wear time. We used accelerometer data to compute step counts in 4-hour blocks and step count variability. Physical function was assessed with the Short Physical Performance Battery (SPPB which includes gait speed test), grip strength, activities of daily living (ADLs) instruments, and life space mobility. We assessed interval fatigue (subjective rating from 0 to 10) on dialysis and non-dialysis days and self-reported recovery time. We assessed the correlations of step count variability with measures of physical function and step count and interval fatigue. Of 37 enrolled participants, 29 had sufficient accelerometer data for analyses. Among the 29 participants, mean (SD) age was 70.6(4.8) years, and 55% (n=16) were male and 72% (n=21) were Black race. Participants were largely sedentary with median (Q1-Q3) self-reported total kilocalories per week of 200 (36-552). Step count variability was positively correlated with measures of physical function: SPPB (r=0.50, p<0.05), gait speed (r=0.59, p<0.05), handgrip strength (r=0.71, p<0.05), Instrumental ADLs (r=0.44, p<0.05) and life space mobility (r=0.54, p<0.05).There was a weak inverse correlation between post-dialysis step counts (4-hour blocks after a dialysis session) and post-dialysis interval fatigue [r=-0.19 (n=102, p=0.06). Physical activity assessment via accelerometer is feasible for older adults receiving hemodialysis. Step count variability correlated with physical function, so it may be a novel measure of physical resilience. Further studies are needed to validate this measure.

Early COVID-19 respiratory risk stratification using machine learning

BackgroundCOVID-19 has strained healthcare systems globally. In this and future pandemics, providers with limited critical care experience must distinguish between moderately ill patients and those who will require aggressive care,...

Moving away from the 4-hour block: Arizona’s distinctive path to reversing its restrictive language policies

ABSTRACT In spring 2019, without controversy or fanfare and without violating the voter mandate of Proposition 203, emergent bilinguals in Arizona were once again granted unrestricted access to dual language bilingual education after nearly 20 years. The policy change was accomplished through a seemingly small piece of legislation that reduced the daily Structured English Immersion requirement from four hours to two hours. In this study, we analyze the Senate and House education committee hearings in which this legislation was unanimously approved before being signed into law by the governor. Using critical discourse analysis and through a theoretical lens of interest convergence, we examine the strategic moves utilized by speakers and legislators to build consensus for this remarkable, yet overlooked, legislation. We found that, in contrast to policy reforms in California and Massachusetts, which used a “multilingualism-for-all” strategy, the speakers and legislators in Arizona focused on English learners. Yet, they worked to show that a change benefitting English learners would also benefit parents, schools, teachers, districts, and even the state of Arizona. Our findings suggest that advocacy for bilingual education that is informed by contextual awareness and translated into the local discourse can produce success, even in conservative contexts such as Arizona.

The Effectiveness of a Pediatric Emergency Medicine Block Education Session for Pediatric Residents.

There exists no standardized curriculum for pediatric residents to develop procedural skills during residency training. Many pediatric residency programs are transitioning to block education sessions; the effectiveness of this format for delivering pediatric emergency medicine (PEM) procedural curriculum has not been evaluated. The objective is to determine if a PEM block education session improved pediatric residents' knowledge and confidence in 4 domains: laceration repair, splinting of extremities, resuscitation/airway management, and point-of-care ultrasound. Pediatric residents at the University of California at San Diego participated in a 4-hour PEM block education session during which they rotated through 4 interactive stations: laceration repair, splinting of extremities, resuscitation/airway management, and point-of-care ultrasound. Residents' knowledge was assessed using 2 distinct multiple-choice tests, each consisting of 20 questions (5 questions per domain). Residents were block randomized to take one version of the test as the pretest and the other version as the posttest. Residents' confidence was assessed for each domain using a standardized 5-point confidence tool before and after the block education session. Forty-five residents attended the PEM block education session. Forty-three residents completed both the preknowledge and postknowledge tests. The PEM block education session resulted in an almost 14% increase in knowledge test when comparing preknowledge and postknowledge scores (P < 0.0001). Significant improvement in resident confidence was seen in all 4 domains (P < 0.0001). The PEM block educational session improved both pediatric residents' knowledge and confidence in domains frequently encountered in the pediatric emergency department.

High prevalence of injection drug use and blood-borne viral infections among patients in an urban emergency department.

The opioid epidemic has led to an increase in the number of persons who inject drugs, and this population accounts for 12% of new human immunodeficiency virus (HIV) and 60% of new hepatitis C virus (HCV) infections in the United States annually. While persons who inject drugs disproportionately utilize the emergency department (ED), accurate data is lacking on the prevalence and patterns of injection drug use, and prevalence of co-occurring HIV and HCV infections among ED patients. The primary outcome was to assess the prevalence of injection drug use and co-occurring HIV and HCV infection among patients presenting to an urban ED. This was a cross sectional study conducted at an urban ED, with an annual census of 65,000 visits. A closed-response questionnaire was developed based on publicly available validated surveys to assess patterns of injection drug use and HIV and HCV infection status, and administered by trained research assistants to all registered adult patients during 4-hour blocks of time. Of the 2,319 eligible patients, 2,200 (94.9%) consented and completed the survey. 241 (11.0%) had ever used injection drugs, 103 (4.7%) currently used injection drugs, and 138 (6.3%) formerly used injection drugs. White patients age 25 to 34 years and white patients age 55 to 64 years had the highest prevalence of current (25.6%) and former (27.1%) injection drug use, respectively. Persons who use injection drugs had a higher prevalence of HCV infection (52.7% vs. 3.4%) and HIV infection (6.2% vs. 1.8%) than the rest of the population. A high prevalence of ED patients report injection drug use, and this population self-reports a high prevalence of HIV and HCV infection. Emergency departments are in a unique position to engage with this population with regards to substance use treatment and linkage to care for HIV and HCV infection.

Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study.

PurposeCervical, oropharyngeal and anogenital cancers are vaccine-preventable diseases, but human papillomavirus (HPV) vaccination coverage in the US remains poor overall with regional variations in vaccination rates. We explore the acceptability by adolescents and their parents of HPV vaccination and text message reminders in the non-traditional setting of the emergency department (ED).Patients and MethodsThe modified validated Carolina HPV Attitudes and Beliefs Scale (CHIAS) survey was administered at two urban EDs to adolescents aged 13–18 years and their parents. Demographic information was collected for each participating adolescent. Recruitment occurred with consecutive eligible participants on the ED census list approached within 4-hour blocks from 8am to 8pm.ResultsNinety-six adolescents completed the survey. The mean adolescent and parental knowledge scores were 63% (SD=29.7) and 60% (SD=22.1), respectively. The higher the HPV knowledge score among both adolescents and parents, the more likely they were to accept HPV vaccine in ED. Among the 10 cases where the parents disagreed to the HPV vaccine and the adolescents agreed to the HPV vaccine, the mean knowledge score among parents disagreeing was 47 compared to 62 among the remaining parents (p=0.04). Sixty-seven percent of adolescents and 68% of parents were agreeable to the adolescent receiving vaccination in the ED (kappa = 0.24). Seventy-five percent of adolescents and 71% of parents reported being agreeable to receiving text reminders for HPV vaccines (kappa = 0.20). Adolescent agreement with receiving a text message reminder corresponded with an increased willingness to be vaccinated (OR=3.21, 95% CI=1.07–9.57, p-value=0.0368). Sexually active adolescents were older (mean age, 17 years) than those who reported no sexual activity (mean age, 15 years) (p<0.0001).ConclusionIncreased knowledge about HPV influences vaccine acceptance. Parents and adolescents may disagree in accepting HPV vaccination. A majority of adolescents and their parents were agreeable to receiving HPV vaccination in the ED and subsequent text message reminders. The ED should be explored further as a non-traditional healthcare setting for HPV vaccination of adolescents.

THE INFLUENCE OF EMOTIONAL IQ ON THE LAGGED RELATIONSHIPS BETWEEN MOMENTARY PAIN AND AFFECT IN OLDER ADULTS

Emotion regulation is influenced by stage of life and time perspective (Carstensen, 1992), with older adults placing greater emphasis on optimizing positive moods and repairing negative ones. Recently, there has been growing interest in emotional intelligence (EI) as a broad indicator of these mood regulation processes. Multiple cross-sectional studies have examined EI, pain and affect in older adults with chronic pain; however, little research has addressed these relationships in temporal context. The current microlongitudinal study addressed this gap by examining (1) lagged relationships between momentary pain and affect, (2) main effects of emotional intelligence (mood attention, clarity and repair) on those relations, and (3) the moderating role of EI on lagged relationships between pain and affect. Three hundred twenty-five older adults (mean age = 63.9) with knee osteoarthritis completed in-person interviews and received four phone calls daily (random within 4-hour blocks) for one week. Multilevel models examined the predictive value of affect from the previous call on current pain, and vice versa, controlling for sociodemographic variables. Across all outcomes (positive affect, negative affect, pain), a significant main effect was found for mood clarity and repair, but not attention. However, EI did not moderate lagged associations between momentary pain and affect. Average pain (across the 28 calls) significantly predicted momentary negative affect, and vice versa. Thus, while emotional intelligence is significantly related to momentary mood states, it does not appear to be related to momentary pain. Implications and ideas for future research are discussed. (R01-AG041655, P. Parmelee & D. Smith, Co-PIs)

Creating a Patient Safety Culture in Obstetrics

To create an innovative, cost-efficient training program that is effective and mindful of the work–life balance of nurses and promotes a culture of patient safety. Discontinue having monthly staff meetings as well as the annual skills fair, which does not include simulation. We implemented a training program that ran in 4-hour blocks for 2 days. There were 144 team members who rotated during the 2 days of training. We collaborated with our partners in the simulation lab; physicians in obstetrics, anesthesia, and neonatology; as well as with respiratory therapists and the rapid response team. From 2017 to 2018, we increased the amount of participation from 30% to 39%. In 2018, the labor and delivery unit had 94% participation rate, the mother-baby unit had 100% participation rate, and the NICU had an 85% participation rate. The hospital’s nulliparous, term, singleton, vertex (NTSV) rate decreased from 26.4% in Quarter 1 (2016) to 13.3% in Quarter 3 (2018). Our timely treatment of hypertension increased from 60% in July 2017 to 89% in October 2018. Our Quarter 1 data from (2016) showed a 0.6% maternal morbidity rate; in Quarter 3 (2018) it was 0.3%. These data are impressive. Create a culture of safety and an environment in which all team members can speak up and seek to understand the “why.” Nurses feel more confident and competent. Training together as a team creates better results. We all speak the same language.

Diurnal variations in the quality of stroke care in Sweden

A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns. Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation. We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off-hours, shifts, day of week, 4-hour, and 12-hour time blocks. We studied hospital resilience by comparing outcomes across hospital types. A total of 113862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime vs daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals. Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals.

Human Papillomavirus (HPV) Knowledge, Vaccine Acceptability and Acceptability of Text Message Reminders for Vaccine Doses in Adolescents Presenting to an Urban Emergency Department (ED)

Abstract Background HPV vaccination has been shown to reduce the incidence of high grade cervical abnormalities in girls under 18 years old and the incidence of genital warts in young men and women under 21 years old. HPV vaccine uptake in the US is low. The 2012 National Immunization Survey–Teen indicated that of girls and boys aged 13–17 years, 33.4% and 6.8% respectively had completed the three dose HPV vaccine. It has been suggested that opportunities for HPV vaccination in less traditional health care settings and using reminder and recall systems may improve HPV vaccine uptake. Methods Adolescents aged 13–18 years old were recruited prospectively from two pediatric EDs in New York City. Recruited patients took part in a researcher-administered questionnaire based on the validated Carolina HPV Attitudes and Beliefs Scale. Demographic information was also collected. Patients were recruited between 8 am and 8 pm and approached consecutively within 4-hour time blocks. Standard descriptive statistics were used to summarize response data. Results Between September 21, 2016 and May 31, 2017, 117 adolescents were interviewed (70 females, 47 males). 76 (65%) had never had their parent or anyone else talk to them about the HPV vaccine. 71 (61%) of adolescents knew the HPV vaccine was not for girls only. 83 (71%) thought that the HPV vaccine was safe. Only 10 (8.5%) of participants thought they were too young to get the vaccine. 35 (30%) answered “yes” when asked if they had ever had sex but only 14 (12%) thought that the HPV vaccine was only for people who are sexually active. 83 (71%) of adolescents would agree, if their parent agreed, to have the HPV vaccine in the ED on the day they were interviewed. 104 (89%) of interviewed adolescents had a mobile phone and 88 (75%) stated they would have no problem with receiving a text message reminder for a vaccine shot. Conclusion Adolescents find it acceptable to receive HPV vaccination in these EDs and text message reminders for subsequent vaccine doses. Exploration of initial HPV vaccination of unvaccinated adolescents in the ED, with follow up doses in more traditional clinic settings aided by text message reminders warrants further investigation. Though a challenging care environment, the ED should not be ignored as a potential site for public health interventions such as HPV vaccination in adolescents. Disclosures All authors: No reported disclosures.

24-hour rhythmicity of seizures in refractory focal epilepsy.

The occurrence of seizures in specific types of epilepsies can follow a 24-hour nonuniform or nonrandom pattern. We described the 24-hour pattern of clinical seizures in patients with focal refractory epilepsy who underwent video-electroencephalography monitoring. Only patients who were candidates for epilepsy surgery with an unequivocal seizure focus were included in the study. A total of 544 seizures from 123 consecutive patients were analyzed. Specific time of seizures were distributed along 3- or 4-hour time blocks or bins throughout the 24-hour period. The mean age of the subjects was 37.7 years, with standard deviation of 11.5 years, median of 37. The majority were females (70/56%). The majority of patients had a seizure focus located in the mesial temporal lobe (102/83%) and in the neocortical temporal lobe (13/11%). The remaining patients had a seizure focus located in the extratemporal lobe (8/6%). The most common etiology was mesial temporal sclerosis (86/69.9%). Nonuniform seizure distribution was observed in seizures arising from the temporal lobe (mesial temporal lobe and neocortical temporal lobe), with two peaks found in both 3- and 4-hour bins: 10:00-13:00/16:00-19:00 and 08:00-12:00/16:00-20:00 respectively (p=0.004). No specific 24-hour pattern was identified in seizures from extratemporal location. The 24-hour rhythmicity of seizure distribution is recognized in certain types of epilepsy, but studies on the topic are scarce. Their replication and validation is therefore needed. Our study confirms the bimodal pattern of temporal lobe epilepsy independently of the nature of the lesion. However, peak times differ between different studies, suggesting that the ambient, rhythmic exogenous factors or environmental/social zeitgebers, may modulate the 24-hour rhythmicity of seizures. Characterization of these 24-hour patterns of seizure occurrence can influence diagnosis and treatment in selected types of epilepsy, such as the case of temporal lobe epilepsy, the most common drug-resistant epilepsy.

Agitation onset, frequency, and associated temporal factors in critically ill adults.

Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.

The sources of pain in knee osteoarthritis are changing dependent upon the progression of the disease

s / Osteoarthritis and Cartilage 21 (2013) S63–S312 S262 Methods: A convenience sample of 28 individuals was studied. All participants had to be 40 yr of age and meet the ACR definition for knee OA. There was no requirement for minimum pain intensity and management was to be continued as required. All participants were asked to response to pings prompted from their smart phones and subsequently rate their knee pain (0: no pain, 10: worst possible) three times per day over 3months. Each of three daily pings was programmed to occur at random in each of three 4-hour blocks (8am-noon, noon4pm, and 4pm-8pm). To characterize the statistical properties of the time series of pain ratings, the means of the pain ratings in three blocks were calculated and compared by one way analysis of covariance. As well, fractal dimension, D, was calculated using rescaled range analysis to characterize the OA participants’ pain fluctuations. Results: Thirty-two individuals participated in the study (18 females, age (mean, standard deviation) 59.7 6.5 yr; 10 males, 55.3 6.7 yr). As shown in Figure A, there is no significant difference among the three blocks of time for the mean rating of pain. Figure B displays the distribution of fractal dimension, D. calculated for each individual's mean daily pain intensity. The mean fractal dimension, D, for the population is 1.65 0.04, which signifies an antipersistent pain time series. Conclusions: This is the first analysis to characterize the fractal dimension of OA pain. The finding of anti-persistent time series means that on average more intense pain is followed by lesser pain, a finding very similar to that reported for chronic low back pain and in contrast to both purely neuropathic pain and acute pain. Whereas these previous studies were over short time periods, this study suggests that power law scaling can be preserved for much longer periods of time (weeks or months), which is significant for clinical application. The anti-persistent pattern of pain is consistent with the concept of central pain processes activated to modulate peripheral pain input in OA.

Reduction in Observation Unit Length of Stay With Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

Further characterization of the influence of crowding on medication errors.

Study Objectives:Our prior analysis suggested that error frequency increases disproportionately with Emergency department (ED) crowding. To further characterize, we measured this association while controlling for the number of charts reviewed and the presence of ambulance diversion status. We hypothesized that errors would occur significantly more frequently as crowding increased, even after controlling for higher patient volumes.Materials and Methods:We performed a prospective, observational study in a large, community hospital ED from May to October of 2009. Our ED has full-time pharmacists who review orders of patients to help identify errors prior to their causing harm. Research volunteers shadowed our ED pharmacists over discrete 4- hour time periods during their reviews of orders on patients in the ED. The total numbers of charts reviewed and errors identified were documented along with details for each error type, severity, and category. We then measured the correlation between error rate (number of errors divided by total number of charts reviewed) and ED occupancy rate while controlling for diversion status during the observational period. We estimated a sample size requirement of at least 45 errors identified to allow detection of an effect size of 0.6 based on our historical data.Results:During 324 hours of surveillance, 1171 charts were reviewed and 87 errors were identified. Median error rate per 4-hour block was 5.8% of charts reviewed (IQR 0-13). No significant change was seen with ED occupancy rate (Spearman's rho = –.08, P = .49). Median error rate during times on ambulance diversion was almost twice as large (11%, IQR 0-17), but this rate did not reach statistical significance in univariate or multivariate analysis.Conclusions:Error frequency appears to remain relatively constant across the range of crowding in our ED when controlling for patient volume via the quantity of orders reviewed. Error quantity therefore increases with crowding, but not at a rate greater than the expected baseline error rate that occurs in uncrowded conditions. These findings suggest that crowding will increase error quantity in a linear fashion.

Implementing Structured English Immersion in Arizona: Benefits, Challenges, and Opportunities

Background/Context Arizona's most recent English Language Learner (ELL) legislation, starting in the school year 2008-2009, requires all such students be educated through a specific Structured English Immersion (SEI) model: the 4-hour English Language Development (ELD) block. The basic premise behind this particular model is that ELL students should be taught the English language quickly so they can then succeed academically. Purpose/Objective/Research Question/Focus of Study This study is the first attempt to look at a random sample of school districts across the state of Arizona under the 4-hour ELD block policy. The goal of the study is to better understand what are the positive aspects and the major challenges of implementing the 4-hour ELD block in Arizona. In particular this study aims to answer the following research questions: (1) How is the 4-hour ELD block being implemented? (2) What are the perceived benefits of the 4-hour ELD block for students and for schools? and (3) What are the district leaders’ concerns about implementing the 4-hour ELD block? Population/Participants/Subjects Of the 65 school districts randomly selected as potential participants, 26 agreed to participate in this study. The district response rate of the study was 40%, and the informants were the English Language Coordinators (ELC), who are the individuals most knowledgeable about how the 4-hour ELD block is implemented in their district. The sample of school districts that participated in our study is representative of the state of Arizona in terms of enrollment patterns. Research Design The researchers designed a phone survey for ELCs. Qualitative data analyses were used to examine the responses of the 26 ELCs. More specifically, a coding scheme was created to assist in the process of organizing and analyzing the data. Findings/Results Analyses reveal that the vast majority of ELCs think that, as a result of the program, there is an increased focus on English Language Learner (ELL) students’ English language development. Regarding the challenges of the program, ELCs think that the implementation of the 4-hour ELD block has: a) neglected core areas of academic content that are critical for ELL students’ academic success, b) contributed to ELL students’ isolation, c) limited ELL students opportunities for on-time high school graduation, and d) assumed that English language learning can be accomplished within an unrealistic time-frame and under a set of unrealistic conditions. Conclusions/Recommendations Given the data collected, we recommend that school districts explore alternative models of ELD instruction. These alternative models of ELD instruction need to take into consideration the local context of school districts, their resources, and existing research. Furthermore, we recommend that ELL students are offered additional programs or types of support that can help them become English proficient, while acquiring the academic content needed for succeeding in school. It seems reasonable to state that a combination of programs and support can be more effective than one prescriptive instructional approach. Finally, we recommend that school districts monitor progress and effectiveness by looking at multiple indicators. In particular, we strongly suggest that school districts keep track of reclassification, re-entry, and opting-out rates.

The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury

Utilization of brain tissue oxygenation (pBtO(2)) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO(2) values over the first 72 hours of monitoring are predictive of mortality. Consecutive, adult patients with severe traumatic brain injury and pBtO(2) monitors were retrospectively identified. Time-indexed measurements of pBtO(2), cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO(2), CPP, and ICP. The pBtO(2) threshold most predictive for survival was determined. There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO(2) values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO(2) was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO(2) was most predictive for mortality. The first 72 hours of pBtO(2) neurologic monitoring predicts mortality. When the pBtO(2) monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO(2) that is predictive of outcome. III, prognostic study.